MEDICAL EVENT DUE TO POTENTIAL DIFFERENT FRACTIONAL DOSE DELIVERED THAN PRESCRIBED

The licensee provided notification that a patient received 2 occurrences of a dose less than prescribed when delivering ten fractions of a treatment. Each of the underdoses were approximately 50% of the 340 Gray prescribed fractional dose. The patient will receive additional dose fractions in order to achieve the written directive total dose. The Radiation Oncologist has notified the patient and attending physician.

* * UPDATE FROM RICHARD MASSOTH TO JOHN KNOKE AT 1826 EST ON 01/31/12 * *

"On January 17, 2012 the NRC Operations Center was verbally notified of two Therapeutic Underdose Occurrences discovered by the licensee on January 16 and 17, 2012. These occurrences involved a fractionated Breast High Dose Rate Afterloader (HDR) treatment with a SenoRx Contura multicatheter breast applicator. The first and third delivered treatment fractions were found to be less than 50% of the intended fractional dose. The entire course of the treatment in the written directive included ten equal-dose fractions of 3.4 Gray per fraction for a total dose of 34 Gray to the prescribed treatment site. To correct for the underdose occurrences, two additional treatment fractions were added and the treatment plan was modified to achieve the total dose specified in the written directive.

"The licensee now believes that this medical event has also caused an unintended dose to skin outside of the prescribed treatment site, requiring notification under 10CFR35.3045(a)(3). The licensee has performed computer simulation, calculations and physical measurements using TLDs simulating the treatment geometry to model the unintended skin dose. The event delivered an unintended skin dose exceeding at least the skin erythema threshold (2 Gy). The licensee is continuing to monitor the patient response to the skin dose and is working to refine the unintended skin dose estimates. An NRC reactive inspection team is on-site."

"At 2148 EDT, on April 10, 2012 the Unit 1 & Unit 2 Safety Parameter Display System (SPDS) and Emergency Response Data System (ERDS) system was removed from service to support a planned maintenance outage on the 1A Engineered Safeguards System (ESS) Bus as part of the U1 17th Refueling and Inspection outage. The Bus Outage is expected to have a duration greater than 8 hours, but less than 72 hours. During this time, required control room hardwire indications will be available from the unaffected ESS buses. An update will be provided when SPDS/ERDS becomes available.

"Since the Unit 1 & Unit 2 SPDS/ERDS computer system will be unavailable for greater than 8 hours, this is considered a Loss of Emergency Assessment Capability and reportable under 10 CFR50.72(b)(3)(xiii)."

A former patient at St. John Macomb-Oakland Hospital expired on 1/31/12 and the body was released to the family for burial. The patient had a Medtronic pacemaker with a radionuclide of Plutonium-238. The RSO at Sinai-Grace Hospital notified the NRC of this event.

There is no planned action to recover the pacemaker from the buried patient.

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

SIX TRITIUM EXIT SIGNS UNACCOUNTED FOR AFTER SHIPPING TO MANUFACTURER

On 1/16/12, the licensee replaced the tritium exit signs in their facility. These exit signs were installed in the late 60's. They put the signs back into the original packaging to return them to the manufacturer. Gexpro [exit sign distributors] picked up the signs with the understanding that they would be shipped to SRB Technologies Inc. (the sign manufacturer). SRB technologies did not receive the signs. A search of the Gexpro warehouse did not locate the signs. Additionally, SRB Technologies had no record of receiving the signs.

A total of 6 tritium exit signs are unaccounted for. The serial numbers of the signs are 600275, 600276, 600277, 600278, and 600279. The remaining exit sign did not have a serial number attached any longer.

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

OFFSITE NOTIFICATION TO STATE AND LOCAL AGENCIES DUE TO NPDES DISCHARGE

"The following ENS is being submitted late.

"On Monday, March 19, 2012 at 3 a.m. a manhole overflowed during a scheduled and permitted radiological release through the cooling tower blow down outfall. As a result, several thousand gallons of water overflowed briefly, formed puddles in the area, and was discharged through a different National Pollutant Discharge Elimination System (NPDES) permitted outfall.

"The overflow was terminated, water samples were collected from the impacted areas, and the area was remediated in keeping with the Station's environmental monitoring program. Several samples showed increased levels of tritium that were well below permitted Commonwealth and Federal effluent limits.

"There were no public health risks associated with this event. The NRC Resident Inspector was notified, and courtesy notifications were made to all appropriate government agencies and local stakeholders in accordance with NEI 07-07, Industry Groundwater Protection Initiative, on March 20, 2012. Due to notification of government agencies, this event is being reported under 10CFR50.72 (b)(2)(xi)."

The licensee informed the Commonwealth of Pennsylvania, and Berks, Montgomery and Chester counties.

"As part of a planned NRC Emergency Plan Exercise on 04/11/2012, local radio and television stations were given access to drill exercise messages to facilitate public awareness of the drill. These messages were plainly marked as 'drill' activity. At 12:40 p.m. CST, an email was sent to Entergy Executive Management showing the contents of a web page that stated in part 'A site area emergency was declared Wednesday at Arkansas Nuclear One, Unit 1, today at 10:18 a.m. by Entergy Operations Inc. officials...' A Little Rock, Arkansas local television station had posted a story on their internet web page at 10:53 a.m., indicating a real event, not a drill activity. The television station News Director stated that once the error was identified, the story was removed from their web page within a matter of minutes. This unplanned media event is being reported in accordance with 10CFR 50.72.(b)(2)(xi)."

"On 4/11/12 at 1807 EDT, with the plant shutdown in Mode 5 during Refueling Outage 15, the 'A' Residual Heat Removal pump tripped while operating in the Shutdown Cooling Mode. The pump trip was due to an isolation of the E1150F009 'Division 1 RHR Shutdown Cooling Inboard Isolation Valve.' This resulted in an interruption of primary decay heat removal for approximately 11 minutes. Approximate calculated time to boil was 23.1 hours. This is being reported under 10CFR50.72(b)(3)(v)(B) 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to remove residual heat.'

"At the time of the pump trip, the station was attempting to restore power to Division 2 Bus 65E from the 64T cross tie bus. A voltage transient occurred due to a fault and caused a Group 4 (Shutdown Cooling/Head Spray) isolation signal. Abnormal Operating Procedure 20.205.01 'Loss of Shutdown Cooling,' was entered, the Group 4 isolation was reset and Shutdown Cooling was restored at 1818 EDT.

"An investigation is in progress to determine the cause of the bus fault."

FITNESS FOR DUTY - A CONTRACT SUPERVISOR TESTED POSITIVE ON A DRUG TEST

A non-licensed contract supervisor tested positive for illegal drugs on a random fitness-for-duty test. The individual's access has been terminated. Contact the Headquarters Operations Officer for additional details.

"At approximately 0930 hours EDT on Thursday, April 12, 2012, the H. B. Robinson Steam Electric Plant, Unit No. 2, Technical Support Center (TSC)/Emergency Response Facility (EOF) air conditioning and charcoal filtration systems will be removed from service to facilitate the replacement of the charcoal filtration media. The duration of work is expected to be approximately 11 hours. Since the unavailability will last greater than 8 hours, this is considered a Loss of Emergency Assessment Capability, and reportable under 10 CFR 50.72(b)(3)(xiii).

"Due to the inability of the TSC/EOF ventilation system to maintain a habitable atmosphere, as a compensatory measure, Emergency Responders assigned to these facilities have been informed to report to the alternate facilities until such time that the TSC/EOF ventilation system has been returned to service.

"TSC/EOF ventilation system maintenance and post maintenance testing is scheduled to be completed by 2030 hours EDT on Thursday April 12, 2012.